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Prudential Individual Life Division
New Appointment Request Cover Sheet
The fully completed application and authorization forms must be returned to Prudential.
 Signature and current date are required on the appointment application (Confidential
Data Sheet)
 Signature and current date are required on the FCRA Disclosure and Authorization.
Completed appointment application forms can be e-mailed, faxed or mailed to:
E-mail: [email protected]
Fax: (800) 875-5965
Prudential Brokerage Appointments
PO Box 70196
Philadelphia, PA 19176
Please note that the Consumer Financial Protection Bureau (CFPB) Notice of Rights and
Disclosure of Rights in California and Washington State are for the broker to review and
retain for his/her records. These documents do not need to be returned to Prudential
with the completed appointment application.
 Requests for information on consumer reports obtained by Prudential can be sent to the
following address:
Prudential Financial
Attn: Compliance – Prehire Manager
One New York Plaza, 16th Floor
New York, NY 10004
 In Good Order appointment submissions include the following requirements:
Fully completed, signed and dated, Confidential Data Sheet (CDS)
Signed & dated FCRA Disclosure Statement and Authorization
Letter of explanation for any “Yes” answers from background information section
Broker Agreement (if applicable)
From: ______________________________
Office: _________________________________
Phone: _____________________________
E-mail: ________________________________
CONFIDENTIAL DATA SHEET
INDIVIDUAL APPOINTMENT APPLICATION – LIFE INSURANCE
Type of Contract - Please check applicable boxes.
Individual (Include signed Broker Agreement)
Selling on behalf of a firm, complete firm information, “Section “C
If selling on behalf of a Broker Dealer with compensation being paid to the B-D, complete “Section D”
A. Producer Information – Complete all fields or mark N/A.
Last Name
First Name
Middle Name
Social Security Number
Date of Birth
E-mail Address
FINRA CRD# (if ever registered)
Business Address/Suite/ P.O Box
City
State
Business Telephone
Fax Number
Zip
Mobile Number
Home Address
City
State
List State(s) to be appointed
Zip
Fixed
Variable
Florida non-resident appointments, list counties
B. Errors & Omission – Required only if contracting as an individual.
Yes
Policy Number
Amount of coverage
Carrier Name
No
C. Firm Information - Complete this section only if selling on behalf of a firm.
** Important** A separate firm CDS is required when contracting and/or appointing a firm.
Firm Name
FEIN or Contract No
Address
City
State
Zip
D. Broker Dealer Information – Complete this section only if selling on behalf of a Broker Dealer.
Broker Dealer Name
B/D FEIN or CRD Number
E. Brokerage General Agency (BGA) Information Section – Complete all fields.
BGA Name
BGA Contract Number
BGA Contact
BGA Phone
BGA E-Mail
F. New Business Information Section – Complete all applicable fields.
Have you submitted new life business with this appointment request?
Yes
Name of proposed insured:
No.
Important - If there is no new business and the appointment is being requested in a jurisdiction that allows
concurrent submission, the appointment request will not be processed but will be held for 90 days from the
date the CDS was signed.
State:
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NR-000004 Ed. 2-14 Ord. 112175 Rev. 2/2014
G. Anti-Money Laundering Certification – Complete if applicable.
Producers affiliated with, employed by, or registered with an entity required under Section 352 of the USA PATRIOT Act
to provide ongoing AML training may satisfy Prudential's AML training requirement by providing satisfactory responses to
the questions below. “Affiliated” in terms of an insurance company and for purposes of satisfying the AML training means
that there is a direct relationship with the insurance company, e.g., a career agent or employed by the insurance
company. An appointment to represent an insurance company does not mean you are “affiliated” with that insurance
company. If you cannot certify completion of an AML training program, Prudential will enroll you in the LIMRA web based
training. A letter of instruction will be provided to you under separate cover.
I certify that I am currently affiliated with or employed by either an insurance company or a bank, located
in the United States that is subject to Section 352 of the USA Patriot Act and that I have completed the
entity's required AML training program.
Yes
No
Name of insurance company or bank
I certify that I am a currently registered with a Broker Dealer located in the United States and that I have
completed the entity's required AML training program.
Yes
No
Name of Broker Dealer
H. Background Information Section – All questions must be answered. Note: A letter of explanation must be
attached to this application for all “Yes” answers to any of the questions below.
1. Have you ever been subject to an insurance or investment related consumer initiated complaint
or proceeding that alleged or found fraud, sales practice violation, forgery, theft, misappropriation
or conversion?
Yes
2. Have you ever been convicted of, pled guilty or nolo contendere to, or are you currently under
indictment for any criminal felony or misdemeanor?
Yes
No
3.
Do you currently have any unsatisfied judgments or liens against you?
Yes
No
4.
Have you ever filed for personal bankruptcy or been declared bankrupt?
Yes
No
5.
Have you ever had an insurance license or appointment or a securities registration suspended
or revoked or been disqualified or disciplined as a member of any profession?
Yes
No
6.
Are you currently party to any litigation or the subject of any investigation?
Yes
No
No
Have you ever been discharged, terminated or permitted to resign, or have you ever voluntarily
resigned while under internal review?
Yes No
I hereby:
• Release Prudential, its authorized agents and any person or entity which provides information pursuant to this
authorization, from any and all liabilities, claims or lawsuits in regards to the information obtained from any and all
sources.
• Certify that all of the information contained in this application is true and correct. I further understand that any
falsification, misrepresentation or omission of information from this form may result in the withholding or withdrawal of
any offer of appointment or the revocation of appointment by Prudential whenever discovered.
• Understand that I am obligated to report immediately any event that would change any of the information, in any
manner, which I have provided in this application.
• Certify that I have not been convicted of any crime that would disqualify me from association with Prudential under the
Violent Crime Control Act and/or Employee Retirement Income Security Act.
7.
Taxpayer Identification Number Certification
Under penalties of perjury, I certify that: (1) The number shown on this form is my correct Social Security number (or I am
waiting for a number to be issued to me), and (2) I am not subject to backup withholding because (a) I am exempt from
backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup
withholding as a result of failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject
to backup withholding, and (3) I am a U.S. citizen or other U.S. person.
The Internal Revenue Service does not require your consent to any provision of this document other than the
certifications required to avoid backup withholding.
_________________________________________________________________________________________________________________________
Licensee’s Signature
Licensee’s Name (Please Print)
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NR-000004 Ed. 2-14 Ord. 112175 Rev. 2/2014
Current Date (MM/DD/YYYY)
DISCLOSURE STATEMENT AND AUTHORIZATION
UNDER THE FAIR CREDIT REPORTING ACT
By this document, The Prudential Insurance Company of America and/or its parent or any of its affiliates, divisions, or
subsidiaries (“Prudential” or the “Company”) discloses to you that a consumer report and/or an investigative consumer
report regarding your criminal history and other background information, credit history, credit worthiness, credit capacity,
and/or credit standing, and which may contain information as to your character, general reputation, personal
characteristics, and/or mode of living may be obtained by the Company. Any consumer report or investigative consumer
report will be obtained in connection with your application for an appointment, in connection with your current
appointment with the Company, or as part of the Company’s consideration of your application to become licensed to sell
insurance.
The Company will only request information regarding your credit history, credit worthiness, credit capacity, and/or credit
standing as permitted by law. Prudential is subject to compliance oversight in accordance with the provisions of 6801 to
6809, inclusive, of Title 15 of the United States Code and state and federal statutes or regulations implementing those
sections.
The nature and scope of the information that Prudential may request includes, but is not limited to: criminal records,
including relevant court records and OFAC/FBI Terrorist Watch List; credit records; education records; employment
records; social security number trace; regulatory reporting history; address history; National Insurance Producer Registry
(NIPR) records; military records; and fingerprint records. A Notice of Rights in California, as applicable, will be provided to
you with this Disclosure.
A consumer report and/or investigative consumer report will be obtained from the following agency:
Business Information Group, Inc. (BIG)
P.O. Box 541
Southampton, PA 18966
800-369-2612
www.bigreport.com
I understand that I am authorizing Prudential to obtain a consumer report and/or an investigative consumer report as part
of the process of its consideration of my application. I understand that this authorization shall remain on file and shall
serve as a continuing authorization for Prudential to procure consumer reports and/or investigative consumer reports for
appointment purposes at any time during my appointment by Prudential, to the maximum extent permissible by law. I
understand that the fact that Prudential may obtain a consumer report and/or investigative consumer report does not
mean, and should not be construed to mean, that Prudential has otherwise decided to offer me an appointment for any
specific duration.
This authorization shall expire upon termination of my appointment with Prudential.
Please sign and date this form in the spaces provided below and retain a copy for your files.
Signature
Date
Print Name
Minnesota, California or Oklahoma candidates may check here to receive a copy of the consumer report/
investigative consumer report.
Massachusetts candidates may receive a copy of the report upon request.
New York candidates have a right to receive and inspect their reports by contacting the consumer reporting
agency.
NR-000004 Ed. 2-14 Ord. 112175 Rev. 2/2014
Para informacion en espanol, visite www.consumerfinance.gov/learnmore o escribe a la
Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and
privacy of information in the files of consumer reporting agencies. There are many types of
consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies
that sell information about check writing histories, medical records, and rental history records).
Here is a summary of your major rights under the FCRA. For more information, including
information about additional rights, go to www.consumerfinance.gov/learnmore or write
to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20006.
•
You must be told if information in your file has been used against you. Anyone who
uses a credit report or another type of consumer report to deny your application for credit,
insurance, or employment – or to take another adverse action against you – must tell you,
and must give you the name, address, and phone number of the agency that provided the
information.
•
You have the right to know what is in your file. You may request and obtain all the
information about you in the files of a consumer reporting agency (your “file
disclosure”). You will be required to provide proper identification, which may include
your Social Security number. In many cases, the disclosure will be free. You are entitled
to a free file disclosure if:
•
•
•
•
•
a person has taken adverse action against you because of information in your credit
report;
you are the victim of identify theft and place a fraud alert in your file;
your file contains inaccurate information as a result of fraud;
you are on public assistance;
you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon
request from each nationwide credit bureau and from nationwide specialty consumer
reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
•
You have the right to ask for a credit score. Credit scores are numerical summaries of
your credit-worthiness based on information from credit bureaus. You may request a
credit score from consumer reporting agencies that create scores or distribute scores used
in residential real property loans, but you will have to pay for it. In some mortgage
transactions, you will receive credit score information for free from the mortgage lender.
•
You have the right to dispute incomplete or inaccurate information. If you identify
information in your file that is incomplete or inaccurate, and report it to the consumer
reporting agency, the agency must investigate unless your dispute is frivolous. See
www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
•
Consumer reporting agencies must correct or delete inaccurate, incomplete, or
unverifiable information. Inaccurate, incomplete or unverifiable information must be
removed or corrected, usually within 30 days. However, a consumer reporting agency
may continue to report information it has verified as accurate.
•
Consumer reporting agencies may not report outdated negative information. In most
cases, a consumer reporting agency may not report negative information that is more than
seven years old, or bankruptcies that are more than 10 years old.
•
Access to your file is limited. A consumer reporting agency may provide information
about you only to people with a valid need – usually to consider an application with a
creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a
valid need for access.
•
You must give your consent for reports to be provided to employers. A consumer
reporting agency may not give out information about you to your employer, or a potential
employer, without your written consent given to the employer. Written consent generally
is not required in the trucking industry. For more information, go to
www.consumerfinance.gov/learnmore.
•
You may limit “prescreened” offers of credit and insurance you get based on
information in your credit report. Unsolicited “prescreened” offers for credit and
insurance must include a toll-free phone number you can call if you choose to remove
your name and address from the lists these offers are based on. You may opt-out with the
nationwide credit bureaus at 1-888-567-8688.
•
You may seek damages from violators. If a consumer reporting agency, or, in some
cases, a user of consumer reports or a furnisher of information to a consumer reporting
agency violates the FCRA, you may be able to sue in state or federal court.
•
Identity theft victims and active duty military personnel have additional rights. For
more information, visit www.consumerfinance.gov/learnmore.
States may enforce the FCRA, and many states have their own consumer reporting laws. In some
cases, you may have more rights under state law. For more information, contact your state or local
consumer protection agency or your state Attorney General. For information about your federal
rights, contact:
TYPE OF BUSINESS:
1.a. Banks, savings associations, and credit unions with
total assets of over $10 billion and their affiliates.
b. Such affiliates that are not banks, savings associations,
or credit unions also should list, in addition to the Bureau:
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and
federal branches and federal agencies of foreign banks
b. State member banks, branches and agencies of foreign
banks (other than federal branches, federal agencies, and
insured state branches of foreign banks), commercial
lending companies owned or controlled by foreign banks,
and organizations operating under section 25 or 25A of
the Federal Reserve Act
c. Nonmember Insured Banks, Insured State Branches of
Foreign Banks, and insured state savings associations
d. Federal Credit Unions
CONTACT:
a. Bureau of Consumer Financial Protection
1700 G Street NW
Washington, DC 20006
b. Federal Trade Commission: Consumer Response Center –
FCRA
Washington, DC 20580
(877) 382-4357
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. Federal Reserve Consumer Help Center
P.O. Box 1200
Minneapolis, MN 55480
c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
d. National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
3. Air carriers
Asst. General Counsel for Aviation Enforcement & Proceedings
Department of Transportation
400 Seventh Street SW
Washington, DC 20590
4. Creditors Subject to Surface Transportation Board
Office of Proceedings, Surface Transportation Board
Department of Transportation
1925 K Street NW
Washington, DC 20423
5. Creditors Subject to Packers and Stockyards Act
Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies
Associate Deputy Administrator for Capital Access
United States Small Business Administration
406 Third Street, SW, 8th Floor
Washington, DC 20416
7. Brokers and Dealers
Securities and Exchange Commission
100 F St NE
Washington, DC 20549
8. Federal Land Banks, Federal Land Bank Associations,
Federal Intermediate Credit Banks, and Production Credit
Associations
Farm Credit Administration
1501 Farm Credit Drive
McLean, VA 22102-5090
9. Retailers, Finance Companies, and All Other Creditors
Not Listed Above
FTC Regional Office for region in which the creditor operates or
Federal Trade Commission: Consumer Response Center – FCRA
Washington, DC 20580
(877) 382-4357
DISCLOSURE OF RIGHTS IN CALIFORNIA AND WASHINGTON STATE
CALIFORNIA RESIDENTS
You have a right under California law to inspect files maintained on you by an investigative consumer
reporting agency pursuant to any of the following procedures, during normal business hours and on
reasonable notice: 1) You may personally inspect the files if you provide proper identification (e.g., valid
driver’s license, social security account number, military identification card, credit cards), and may
receive a copy of the file for the actual cost of duplication services provided. 2) You may make a written
request, by certified mail and with proper identification, as described above, for copies to be sent to a
specified addressee. 3) You may make a written request, with proper identification as described above, for
telephone disclosure of a summary of information contained in your files, if any toll charge is prepaid by
or charged directly to you. If you are unable to provide "proper identification" through the types of cards
or numbers listed above, the agency may require additional information concerning your employment and
personal or family history in order to verify your identity. The agency must provide trained personnel to
explain to you any information that the agency is required to furnish to you from your file. The agency
also must provide you with a written explanation of any coded information contained in your files at the
time inspection of your files is permitted. You are permitted by law to be accompanied by one other
person of your choosing when inspecting your files. That person must furnish reasonable identification.
The agency may require you to provide the agency with a written statement granting permission to the
agency to discuss your file in such person’s presence. The agency also is not required by law to make
available to you the sources of information in your files, although such information would be obtainable
through proper discovery procedures in any court action brought under Title 1.6A of the Civil Code
pertaining to Investigative Consumer Reporting Agencies.
NOTICE OF RIGHTS - STATE OF WASHINGTON FAIR CREDIT REPORTING ACT
Washington’s Fair Credit Reporting Act (19 RCW 476) requires reporting agencies to provide you a
summary of your rights and remedies under the law when providing you with a written copy of your
credit report. Under the Washington law, an employer who wishes to obtain a consumer report and/or an
investigative consumer report for someone who is not an employee, such as an applicant, must make a
written disclosure advising the individual that such a report may be obtained; must obtain the consent of
that individual before obtaining such a report; and, if an investigative consumer report is to be obtained,
must provide the individual with a summary of rights and remedies under the law. Under the Washington
law you have a right:
To have your name and address excluded from any list provided by a consumer reporting agency in
connection with a credit transaction or direct solicitation you do not initiate. You must notify the
consumer reporting agency in writing through the notification system maintained by the agency, and must
include a statement that you do not consent to any use of consumer reports relating to you in connection
with any transaction you did not initiate.
To request a consumer reporting agency to disclose all information in its file on you at the time of your
request, including disclosure of the sources of the information.
To the identification of each person or business which obtained your report for employment purposes
during the two years prior to your request, and each person or business which obtained your report for any
other purpose within six months prior to your request, including those inquiries in connection with a
credit transaction you did not initiate. Identification will include the name of the person or trade name
under which the person conducts business, and, if you request, that person’s business’ address.
To receive credit file disclosures during normal business hours and on reasonable notice (1) in person, if
you appear in person and furnish proper identification, (2) by telephone, if you make written request with
proper identification and pay for any toll charges, or (3) by any other reasonable means available to the
consumer reporting agency and authorized by you. For in-person disclosure, you may be accompanied by
one other person of your choosing, although you may be required to furnish written permission for your
credit file to be discussed in the other person’s presence. If a credit score is disclosed as part of your
credit report, you will be provided an explanation of the meaning of the credit score.
To an explanation of how you may exercise rights and remedies under the Washington law, including the
name, address, and phone number of the agency responsible for enforcing this law. You may write to the
Attorney General, 1125 Washington St. SE,, P.O. Box 40100, Olympia, WA 98504-0100, or call (360)
753-6200.
To notify the consumer reporting agency if you dispute the completeness or accuracy of any item or
information in your consumer report or your investigative consumer report, and to have disputed items
reinvestigated without charge, and the current status of the disputed information recorded in your file
within 30 business days from the date the consumer reporting agency receives your dispute. You will be
notified if the agency stops reinvestigating disputed information upon determining the dispute is frivolous
or irrelevant, including failure on your part to provide sufficient information relative to the dispute. Such
notice will be in writing within five business days after the determination that the dispute if frivolous or
irrelevant.
To have the consumer reporting agency review all information you submit which is relevant to the
disputed information.
To receive notification from the consumer reporting agency when information you disputed is deleted
from your file because it could not be verified, but is subsequently found to be complete and accurate and
is reinserted into your file.
To file a brief statement with the consumer reporting agency setting forth the nature of your dispute, if the
reinvestigation does not resolve the dispute or it is found to be frivolous or irrelevant. Your statement
may be limited by the consumer reporting agency, provided you receive help from the agency in writing a
clear summary of the dispute.
To request that the consumer reporting agency, when a disputed item of information has been depleted or
remains on file with a statement of dispute, to provide notification to any person you designate who,
within the past two years, received a copy of your consumer report for employment purposes, or who,
within the past six months, received a copy of your consumer report for any other purpose.
To receive the results of the reinvestigation of disputed information within five business days following
completion of the reinvestigation.
To request the consumer reporting agency to provide you with a description of the procedure used to
determine the accuracy and completeness of the information disputed, including the name, business
address, and telephone number of the person or business contacted during the reinvestigation.
To receive disclosure of the information in your file without charge, if requested within 60 days following
your receipt of a notice denying you credit, employment, insurance, or other benefit, or notification from
a debt collection agency stating that your credit may be or has been impaired. No charges will be
imposed for nay reinvestigation of disputed information, deletion of information found to be inaccurate,
or for assisting you in filing your statement of dispute, for notifying persons who previously received
your consumer report.
To receive, from a user of consumer reports (such as a creditor or employer), which has taken adverse
action regarding you based on your report,(a) notice of the action taken, and (b) the name, address and
telephone number of the consumer reporting agency that furnished the report. Notice of adverse action
must be in writing, except verbal notice may be given if the business is regulated by the Washington
Utilities and Transportation Commission, or involves an application for the rental and leasing of
residential real estate.
To bring legal action against a consumer reporting agency or an employer for failure to comply with its
obligations under this law, if you do so within two years after the failure to comply (unless the consumer
reporting agency or the employer materially and willfully failed to comply, in which case you may file
legal action anytime within two years after you learn the agency or employer has done so).
CONFIDENTIAL DATA SHEET
FIRM APPOINTMENT APPLICATION – LIFE INSURANCE
A. Contracting Information – Complete all fields and include a signed Brokerage Firm Agreement.
Firm Name
Firm FEIN
Business Address/Suite/P.O. Box
City
State
Firm Phone Number
Zip
Firm Fax Number
Firm contact E-Mail address
List state(s) where the firm is to be appointed
B. Errors & Omission – Complete all fields.
Policy Number
Amount of coverage
Yes
Carrier Name
No
Important Note
Firm appointments in Arkansas, Hawaii, Michigan and/or South Dakota, require the appointment of the firm’s
Principal or another designated Responsible Individual. Please also complete an “Individual CDS/ Appointment
Application” (Ord. 112175) for that individual.
C. Principal Information– Complete all fields.
Last Name
First Name
Middle Name
Social Security Number
Date of Birth
FINRA CRD# (if ever registered)
D. Brokerage General Agency (BGA) Information – Complete all fields.
BGA Name
BGA Contract Number
E. Producer Information – Complete all fields.
Name of producer selling on behalf of firm
Social Security Number
Page 1 of 2
NR-016976 Ed. 02-14 Ord.114614 Rev. 2/2014
CONFIDENTIAL DATA SHEET
FIRM APPOINTMENT APPLICATION – LIFE INSURANCE
F. Background Information Section – These questions are to be answered by the firm principal on behalf of the
firm. All questions must be answered.
IF “YES” IS ANSWERED TO ANY OF THE QUESTIONS BELOW, A LETTER OF EXPLANATION MUST BE
ATTACHED TO THIS APPOINTMENT APPLICATION.
2.
Has the firm ever been subject to an insurance or investment related consumer initiated complaint
or proceeding that alleged or found fraud, sales practice violation, forgery, theft, misappropriation
or conversion?
Does the firm have any unsatisfied judgments or liens against it?
Yes
Yes
No
No
3.
Has the firm ever filed for bankruptcy or been declared bankrupt?
Yes
No
4.
Has the firm ever had an insurance license or appointment or a securities registration suspended
or revoked or been disqualified or disciplined as a member of any profession?
Yes
No
5.
Is the firm currently party to any litigation or the subject of any investigation?
Yes
No
1.
I hereby:
• Release Prudential, its authorized agents and any person or entity which provides information pursuant to this
authorization, from any and all liabilities, claims or lawsuits in regards to the information obtained from any and all
sources.
• Certify that all of the information contained in this application is true and correct. I further understand that any
falsification, misrepresentation or omission of information from this form may result in the withholding or withdrawal of
any offer of appointment or the revocation of appointment by Prudential whenever discovered.
• Understand that I am obligated to report immediately any event that would change any of the information, in any
manner, which I have provided in this application.
• Certify that neither the firm nor any of its employees or representatives engaging in the business of insurance, including
myself, have ever been convicted of any crime that would disqualify any of us from association with Prudential under the
Violent Crime Control Act and/or Employee Retirement Income Security Act."
Taxpayer Identification Number Certification
Under penalties of perjury, I certify that: (1) The number shown on this form is the correct Tax Payer Identification
number (or I am waiting for a number to be issued to me), and (2) I am not subject to backup withholding because
(a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that
I am subject to backup withholding as a result of failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and (3) I am a U.S. citizen or other U.S. person.
The Internal Revenue Service does not require your consent to any provision of this document other than the certifications
required to avoid backup withholding.
_________________________________________________________________________________________________
Firm Principle Signature
Firm Principle (Please Print)
Current Date (MM/DD/YYY)
Page 2 of 2
NR-016976 Ed. 02-14 Ord.114614 Rev. 2/2014
Broker Agreement (Life Insurance)
This Broker agreement (hereinafter, the “Agreement”) is between The Prudential Insurance Company of America, Pruco
Life Insurance Company, and Pruco Life Insurance Company of New Jersey (hereinafter collectively, the “Company”)
and the individual whose name appears on page ten of this Agreement (hereinafter, the “Broker”).
1.
Appointment - The Company appoints the Broker as a non-exclusive insurance agent to solicit applications for
the non-Securities Exchange Commission (“SEC”) registered life insurance policies (hereinafter individually,
the “Policy” or collectively, the “Policies”) of the Company. Such Policies are identified as Eligible Products in
a List of Eligible Products (hereinafter, “Exhibit A”) attached hereto. From time to time Exhibit A may be
updated or amended by the Company. Such updates or amendments will be effective upon notice, as defined in
Section 15(f), (hereinafter, “Notice”) to the Broker that a new or amended Exhibit A has been issued. The
Company will have the sole discretion to appoint any Broker and any employee or representative of the Broker
as an insurance agent of the Company.
2.
Authority and Undertaking –
a.
This Agreement authorizes the Broker to:
i.
solicit, procure and submit applications for Policies of the Company, provided the Broker is properly
state licensed and state appointed to do so, as required by the Company’s Licensing, Appointment and
Registration Policy (hereinafter the Company’s “Licensing, Appointment and Registration Policy”);
ii.
ensure that all Policy placement requirements are satisfied and to deliver Policies to policyowners; and
iii. assist policyowners in obtaining prompt service from the Company with respect to the administration
of Policies, and in maintaining their coverage as long as that coverage is in the interest of the
policyowner.
b.
Broker agrees to the following undertaking in its capacity as a Broker with regard to its employees and
representatives for Policies:
i.
3.
Broker has full responsibility for the supervision of all employees and representatives who are
engaged, directly or indirectly, in performing administrative functions on Broker’s behalf to ensure
that they are in compliance with all applicable federal, state and local laws and regulations and all rules
and procedures of the Company (which rules and procedures may be changed by the Company at its
own discretion).
Limitations of Broker's Authority - The Broker’s authority is limited to what is authorized in Section 2. This
section is intended to provide examples, not an entire listing, of actions that are outside the authority granted in
Section 2. Broker agrees that its authorization is limited to solicitation of applications and marketing of Policies in
accordance with this Agreement. Broker represents and agrees on behalf of himself and employees and
representatives that none of them will act in a manner not authorized by this Agreement and that any such
unauthorized action, including but not limited to the following actions, would be considered a breach of this
Agreement:
a.
bind the Company except as specifically authorized by this Agreement;
b.
make representations as an agent of the Company in any manner or for any purpose except as specifically
authorized by this Agreement;
c.
make, alter or modify any Policy or receipt;
d.
waive any provision or condition of any Policy issued by the Company;
e.
extend the time for payment of any premium on any Policy, bind the Company to the reinstatement of any
terminated Policy or accept promissory notes for payment of premiums on any Policy;
f.
adjust or settle any claim or commit the Company with respect to any claim, except as specifically directed in
writing by the Company;
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g.
provide or offer to provide any inducement not specified in the Policy or any rebate, either directly or
indirectly, to any person or entity, as an inducement to purchase any Policy;
h.
accept funds, unless those funds are payable to the Company and only under the following circumstances:
i.
when the application and the funds are submitted simultaneously and the Company’s standards for
prepaid applications have been met, or;
ii.
the Company’s delivery requirements have been met and the Policy has been delivered, and;
iii. such funds must be remitted to the Company within one business day of receipt;
i.
incur any expense or liability on account of the Company without specific written authority to do so from
the Company;
j.
demand or accept any remuneration other than what is provided by the Company for rendering any service
specifically related to the normal maintenance and care of the Company’s business. This provision does
not prohibit the Broker from accepting fees for any services provided by the Broker other than those
authorized by this Agreement;
k.
make any misrepresentation or incomplete comparison for the purpose of inducing a potential or actual
policyowner to purchase, convert, lapse, surrender all or any portion of, forfeit, borrow from, or replace any
Policies;
l.
induce or attempt to induce any policyowner to replace or relinquish a policy or to withdraw values from a
policy when doing so would be in violation of the Company’s Replacement Policy or any state or federal
law or regulation or not in the interest of the customer;
m. solicit, procure or submit applications for the SEC registered life insurance policies of the Company which
are controlled by selling agreements between FINRA member broker dealers;
4.
n.
deliver, or allow the delivery of, the Policy unless the health of the proposed insured(s) is in accordance with
the Company’s requirements, if any, and, where required, the first premium is paid in full;
o.
request that a client pre-sign any Policy related form for use at a later date, request a client to sign any Policy
related forms unless completed in its entirety or accept any signed Policy related form unless said forms are
complete and ready for submission to the Company;
p.
engage in any insurance transaction that requires compensation disclosure, as determined by the applicable law,
without making such required compensation disclosure; and
q.
solicit applications for Policies on military installations or otherwise engage in activity contrary to instruction
provided by the US Department of Defense or state law regarding such.
Broker’s Representations - The Broker represents and agrees:
a.
to abide by the Company’s policies and procedures related to the solicitation and sale of Policies, which are
identified on Exhibit B and made a part hereof;
b.
to abide by any revised or additional policies and procedures that the Company communicates;
c.
to review and become familiar with the Company’s Policies prior to soliciting applications for these
Policies;
d.
that the Broker and its employees or representatives will comply with all applicable insurance laws, regulations
and requirements and all other applicable state and federal laws, regulations and requirements in soliciting
applications for Policies; that the Broker will be fully responsible for all acts of its employees or representatives
in soliciting applications for Policies;
e.
to use fact finding tools for determining applicant’s insurable needs and financial objectives;
f.
to solicit applications for Policies only from applicants for whom the Policies are suitable;
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g.
to solicit, procure and submit applications for Policies only if properly state licensed and state appointed to
do so as required by the Company’s Licensing, Appointment and Registration Policy and to provide the
Company copies of all licenses;
h.
that the Broker will not solicit applications for Policies in any state unless the Policy has been approved for
sale in that state;
i.
to assist policyowners in obtaining prompt service from the Company with respect to the administration of
Policies and in maintaining their coverage as long as that coverage is in the interest of the policyowner;
j.
that all terms and conditions of this Agreement apply to any employee or representative of the Broker who
solicits applications for Policies on behalf of the Broker; and the Broker further agrees to ensure that such
employees or representatives comply with all terms and conditions of this Agreement. Furthermore, Broker
agrees to notify Company immediately if Broker, its employees or representative breach any terms or
conditions of this agreement;
k.
that except as disclosed to the Company on the Broker’s application for appointment:
i.
neither the Broker's insurance license nor the insurance license of any of its employees or representatives
has ever been revoked, suspended, or rescinded in any state or jurisdiction;
ii.
neither the Broker nor any of its employees or representatives has ever been fined by any insurance
regulator in an amount of $5,000 or more;
iii. and neither the Broker nor any of its employees or representatives are currently the subject of any
disciplinary proceeding or investigation in any state or jurisdiction by any Department of Insurance,
Attorney General’s office or other governmental authority;
l.
that except as disclosed to the Company on the Broker’s application for appointment:
i.
if the Broker or any of its employees or representatives is or has ever been a registered principal or
representative of a member of the FINRA, the said registration with the FINRA is not now and never has
been suspended, revoked or canceled;
ii.
neither the Broker nor any of its employees or representatives has ever been fined by the FINRA or other
self-regulatory organization in an amount of $5,000 or more;
iii. and neither the Broker nor any of its employees or representatives is currently the subject of any
disciplinary proceeding or investigation by the SEC or FINRA;
m. that neither the Broker nor any of its employees or representatives has ever been convicted of any felony or of
any offense set forth in United States Code Title 18, Part I, Chapter 47, Section 1033 pertaining to “Crimes by or
affecting persons engaged in the business of insurance whose activities affect interstate commerce”;
n.
that Broker, upon request of Company, shall, within thirty (30) days of receipt, return to Company a
questionnaire or certification regarding any regulatory, civil and/or criminal proceedings, including
arbitration, against the Broker or any employee or representative commenced or concluded by any state
insurance or securities department, FINRA or other self-regulatory organization, and/or in any court of
competent jurisdiction. Broker shall provide Company with a full explanation regarding matters disclosed
in the questionnaire or certification;
o.
that Broker will promptly notify the Company of any allegation that the Broker, or any of its employees or
representatives, violated any law or regulation which may impact their ability to represent the Company;
p.
that the Broker will notify the Company in writing immediately of the termination of the employment or
affiliation of an employee or representative who is appointed to represent the Company pursuant to this
Agreement;
q.
that with regard to any bank marketing, Broker will comply with the disclosure and advertising requirements
implemented by the Board of Governors of the Federal Reserve System, the Federal Deposit Insurance
Corporation, the Office of the Comptroller of the Currency and the Office of Thrift Supervision, including but
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not limited to disclosure with the respect to the sale or recommendation of Policies, illustrations, disclosures
and all other applicable laws and requirements;
5.
r.
that no Company Policy shall be sold where, at the time of delivery, the Broker or anyone associated with
Broker has knowledge that there is a practice or plan to initiate a life insurance policy for the benefit of a
third party investor who, at the time of such policy origination, has no insurable interest in the insured.
s.
that Broker and anyone associated with Broker will not participate directly or indirectly in any transaction
where a Company Policy is sold to or used in any manner with a viatical or life settlement company or is
part of a viatical or life settlement.
t.
to complete a permanent registration for the PrudentialXpress website at www.pruxpress.com (hereinafter,
the “Website”) within 30 days of the effective date of the Agreement. Use of the Website will be subject to
the terms and conditions of the Website;
u.
for the term of the Agreement, to access the Website no less frequently than once every 90 days and to read
and review the "Notices & Schedules" page of the Licensing section; and
v.
for the term of the Agreement, to maintain an active Website registration.
Independent Contractor - The Broker is an independent contractor and is not an employee of the Company. The
Broker is free to exercise independent judgment as to the time, place and means of performing the authority granted,
subject to the terms and conditions of this Agreement. The Broker’s business and any services provided by the
Broker, other than those authorized by this Agreement are not and will not be represented to be the business of the
Company.
Service provided by the Broker to any policyowner in connection with any employee benefit program or employee
compensation program of any nature is not and will not be represented to be the business of the Company regardless
of the use of a Policy or group of Policies issued by the Company in conjunction with the aforesaid program.
6.
Advertisements and Marketing Materials – The Broker agrees that any material it develops, approves or uses for
sales, training, explanatory or other purposes that mentions by name the Policies or Company (or any affiliate of the
Company or any logos of any of them) will not be used without prior written consent of the Company. The Broker
will not publish, issue, circulate or use in any manner whatsoever any advertisements or marketing materials
describing or referring to the Company, the Policies or any product of the Company unless such advertisements or
marketing materials have been approved in writing in advance by the Company.
The Broker will not misrepresent the Policies or the Company and will make no oral or written representation which
is inconsistent with the terms of the Policies or with the information in any illustration or sales literature furnished
by the Company.
7.
Errors and Omissions - The Broker agrees to maintain Errors and Omissions coverage with unimpaired limits of
not less than one million dollars and to provide evidence of such coverage satisfactory to the Company upon request
by the Company. The Broker will notify the Company in writing immediately if the coverage is terminated or
suspended.
8.
Indemnity - The following indemnification will apply:
a.
the Company will indemnify, defend and hold harmless the Broker, its employees or representatives against
any losses, claims, damages, judgments, liabilities, penalties or expenses of any nature, including but not
limited to reasonable attorneys’ fees and court costs which arise out of or are based upon any untrue
statement or alleged untrue statement of a material fact contained in any sales material written and/or
approved by the Company;
b.
the Broker will indemnify, defend and hold harmless the Company, its affiliates, directors, officers, and
agents against any losses, claims, damages, judgments, liabilities, penalties or expenses of any nature,
including but not limited to reasonable attorneys’ fees and court costs which arise out of or are based upon
any unauthorized use of sales materials or any verbal or written misrepresentations or any unlawful sales
practices, or failure of the Broker or its employees or representatives to comply with the provisions of this
agreement or the willful misfeasance, bad faith, negligence or misconduct of the Broker or its employees or
representatives in the solicitation of applications for, or sale of, Policies.
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The indemnification will survive the termination of this Agreement.
9.
Complaints, Investigations, Proceedings and Books and Records - Broker agrees to immediately provide Notice
to Company of any Policy complaints, investigations or disciplinary proceedings received by Broker or any of its
employees or representatives relating to the Policies, Company or any threatened or filed action or civil litigation
arising out of the conduct of business under this Agreement. Additionally, Broker shall immediately forward to
Company, by certified mail and to the address provided for Notice in this Agreement any legal process or notice of
claims served on Broker or any of its employees or representatives in a suit or proceeding against Broker or any of
its employees or representatives arising out of the conduct of business under this Agreement.
Broker and any of its employees and representatives shall cooperate with Company in investigating and responding
to any complaint, attorney demand, or inquiry received from state insurance departments or other regulatory
agencies or legislative bodies, and in any settlement or trial of any actions arising out of the conduct of business
under this Agreement. Cooperate, as referred to in this provision, shall include, but is not limited to, the provision of
information as may be necessary to furnish Company with a complete understanding of the facts and circumstances
surrounding the complaint, demand or inquiry.
Any response by Broker or any of its employees or representatives to a Policy complaint arising out of the conduct
of business under this Agreement must be sent to Company for its approval before being sent. Any responses to
such Policy complaints must be sent to Company not less than fifteen (15) business days before being sent, except
that if a more prompt response is required, the proposed response may be communicated to Company.
Broker and any of its employees or representatives are not authorized, and are expressly forbidden, from settling or
offering to settle any complaint or litigation from a Policy owner, assignee, beneficiary or other party in interest to a
Policy.
The Broker shall have the responsibility for maintaining accurate and complete records of all transactions relating to
the solicitation of applications and the sale of Policies for the Company as required of it by applicable federal and
state laws and regulations. These records will be made available to the Company for inspection upon request,
including after termination of this Agreement. The records maintained by Broker under the terms of this Agreement
that relate to the sale of Policies, shall be maintained so as to clearly and accurately disclose the nature and details of
the transactions as required by appropriate laws, rules and regulations and for the period required by law. Broker
shall also comply with any record hold order issued by the Company.
10. Compensation - In consideration of and as full compensation for the services performed in accordance with this
Agreement, the Broker will receive compensation from the Company either, (1) as set forth in the Company’s
Commission Schedule posted to the Website in effect as of the date of issue, as determined by the Company, for
each Policy or; (2) if the Company determines the Broker is eligible for any expense allowances or a
compensation arrangement that differs from the Commission Schedules posted to the Website, such
compensation will be communicated to the Broker in writing in a separate Schedule (“Compensation”). The
Broker will only be entitled to Compensation for Policies that have been submitted by the Broker, accepted by the
Company, delivered by the Broker and where all the requirements of the Company’s Licensing, Appointment and
Registration Policy have been satisfied, subject to the following provisions:
a.
Any amount due the Company from the Broker, whether arising from this or any other agreement with the
Company, will be repaid by any amount payable under this Agreement, until the amount of such
indebtedness is fully paid.
b.
If the Company returns, for any reason, any premiums or purchase payments on any Policy, rescinds the
Policy or considers the Policy to be void from inception, the Broker will have an immediate obligation to,
and will upon demand, repay the Company all the Compensation previously received by the Broker as a
result of those premiums or purchase payments.
c.
When two or more Brokers are listed as the writing representative on an application, Compensation for that
Policy will be payable in the proportion as directed on the application or in a writing acceptable to the
Company.
d.
Compensation due is vested to the writing Broker or the writing Broker’s estate, for the period set forth in
the Policy Commission Schedule and, if applicable, a separate compensation schedule, provided premiums
continue to be paid and such receipt of Compensation is permitted by applicable regulatory agencies.
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e.
No Compensation is payable to the Broker after the Policy has lapsed, or after the discontinuance of
premium payments, but should the Broker secure the reinstatement of said Policy, while properly licensed
to do so, the Company will pay compensation to the Broker on premiums collected, as though the Policy
had not lapsed. If the time between the lapse and reinstatement is greater than three months, all
Compensation (current and future) shall be payable based upon the original issue date of the policy to the
Broker who secures the reinstatement and signs the reinstatement form.
f.
Service Commissions, if applicable, as defined in the Company’s Commission Schedule, shall be payable
for the period and upon the terms set forth in the Commission Schedule.
g.
After the first policy year, no Compensation will be paid on any premium that is waived.
h.
No assignment of Compensation is valid against the Company unless acknowledged in writing by the
Company.
i.
If a Policy replaces, in whole or in part, a policy or contract previously issued by this or any other insurance
company, the Company has the right to determine what, if any, Compensation will be allowed.
j.
If a Policy is changed to a different kind or amount, or if its date is changed, the Company has the right to
determine what, if any, Compensation will be allowed.
k.
No Compensation will be paid on any Policy issued as the result of the conversion of group life insurance.
l.
The Company will not be obligated to pay any Compensation which would be in violation of applicable
laws or regulations of any jurisdiction, anything in this Agreement to the contrary notwithstanding.
m. Notwithstanding any provision of this Agreement to the contrary, if the transaction is subject to the
jurisdiction of the New York Insurance Department, no Compensation in excess of the compensation limits
established by the Insurance Law of the State of New York will be due or payable by the Company to
Broker.
n.
Compensation on premiums paid more than three months in advance are payable on the date the premiums
are due.
o.
All premiums and Compensation is payable in U.S. currency.
p.
No Compensation is payable on any extra war risk premium which may be charged in connection with any
Policy.
11. Privacy - Each party acknowledges that they may be provided with information or access information about
customers of Company or Broker (“Customer Information”).
Each party agrees to comply with any federal, state, provincial and/or local law or regulation related to privacy.
Furthermore, each party represents and warrants that it has implemented and currently maintains an effective
information security program to protect the Customer Information, which program includes administrative,
technical, and physical safeguards:
a)
to ensure the security and confidentiality of Customer Information;
b) to protect against any anticipated threats or hazards to the security or integrity of such Customer
Information; and
c)
to protect against unauthorized access to or use of Customer Information which could result in substantial
harm or inconvenience to either party or other affiliates, or to customers of any of them.
Broker shall promptly notify Company if Broker is in material breach of this provision. Broker shall promptly
notify Company if it has suffered a breach of security of personal information affecting any consumer to whom
Broker has sold any Company Policy.
Each party agrees that it shall keep and maintain all Confidential Information (as defined below) in strict
confidence, using such degree of care as is appropriate to avoid unauthorized use or disclosure; and shall use
and disclose Confidential Information solely for the purposes for which such information, or access to it, is
provided pursuant to the terms of this Agreement. Each party further agrees that it shall not, directly or
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indirectly; disclose Confidential Information to any third party, except with the disclosing party’s prior written
consent or as permitted under the terms of this Agreement.
For purposes of this provision, Confidential Information is defined as information respecting all past, present or
future business activities of each party, written or oral, including without limitation: information relating to a
party’s planned or existing businesses or initiatives; organizational restructuring plans; actual and projected
sales, profits and other financial information; technology (computer systems and architecture, computer
hardware and software, methods); processing and operational methods; insurance, annuities and financial
services product strategies, actuarial calculations, designs, administration and management; tax interpretations
or positions; information respecting or materials of third parties with whom a party conducts business; and
employees and personnel; and any policies, procedures and standards. Notwithstanding the foregoing,
Confidential Information does not include information that (i) is lawfully made available to the general public,
(ii) is or becomes generally known to the public not as a result of a disclosure by the receiving party, (iii) is
rightfully in the possession of the receiving party prior to disclosure by the disclosing party, (iv) is received by a
party in good faith and without restriction from a third party reasonably believed to have the right to make such
disclosure, or (v) is independently developed by or for the receiving party without use or reference to the
Confidential Information.
12. Anti-Money Laundering
a.
Broker represents and agrees that it has reviewed and is familiar with (i) applicable laws, regulations, rules and
guidance governing the detection, prevention and reporting of money laundering and terrorist financing
activities, including, but not limited to: (1) provisions of the USA PATRIOT Act of 2001 and regulations
thereunder; (2) provisions of the Bank Secrecy Act and regulations thereunder; (3) relevant rules and
regulations promulgated by the Office of Foreign Assets Control; and (4) all record keeping, reporting and
auditing requirements of these laws, regulations and rules; and (ii) Company’s Anti-Money Laundering
Program.
b.
Broker agrees to complete Company’s Anti-Money Laundering training provided by LIMRA, or such training
approved in advance by Company in writing, concerning the detection, prevention and reporting of money
laundering and terrorist financing activities, when and as required by Company. Broker agrees to provide
Company with a certification, upon request, that it has completed such training and detailing the subject matter
and dates of such training and the persons trained.
c.
Broker agrees to report to Company any transaction, or pattern of transactions, that it knows, suspects, or has
reason to suspect: (i) involves funds derived from illegal activity (including, without limitation, the ownership,
nature, source, location, or control of such funds or assets) as part of a plan to violate or evade any federal law
or regulation or to avoid any transaction reporting requirement under federal law or regulation or is intended or
conducted to hide or disguise funds or assets derived from illegal activity; (ii) is designed, whether through
structuring or other means, to evade the requirements of the Bank Secrecy Act or any regulations promulgated
thereunder; (iii) has no business or apparent lawful purpose or is not the sort in which the particular customer
would normally be expected to engage; or (iv) involves the use of Company to facilitate criminal activity.
Broker agrees to comply with any requests from Company for assistance in the detection or investigation of
potential suspicious transactions in a timely manner. Broker agrees and acknowledges that notice to any
individual of any investigation or reporting involving a suspicious transaction or activity is prohibited by
federal law and agrees to ensure the confidentiality of any such investigation or reporting.
d.
Broker agrees to permit inspection relating to its compliance with the foregoing by any U.S. federal regulatory
or law enforcement agency having jurisdiction and will make available to examiners from such agencies such
records and information as they may request relating thereto.
e.
Company shall have the right, upon reasonable notice, to obtain and review documentation evidencing
compliance with Company’s Anti-Money Laundering Program and the foregoing laws, regulations and rules.
13. Termination
a.
This Agreement may be terminated with or without cause by either party immediately upon Notice to the
other party.
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b.
The Agreement will terminate automatically at the date and hour of the suspension, revocation, cancellation
or rescission of any state insurance license or FINRA license or registration of the Broker.
c.
The Agreement will terminate immediately upon Notice by the Company of the cancellation of all the
Broker’s state insurance appointments.
d.
Compensation according to the terms of this Agreement will survive the termination of this Agreement,
subject to any conditions imposed by law on payment of compensation.
e.
The Company may at any time, in its sole discretion, withhold or withdraw authority of any employee or
representative of the Broker to solicit applications for Policies. Upon the Company giving Notice to the
Broker of its withdrawal of authority of an employee or representative to solicit applications, the Broker
will immediately ensure that any such employee or representative cease all such solicitations.
14. Effective Date - This Agreement is effective once fully executed by both the Company and the Broker. The
Effective Date shall be the date the Company executes the Agreement.
15. General Provisions
a.
Entire Agreement - Except as is provided in long-term care broker, general agent and broker dealer
agreements, if any, this Agreement and its schedules and attachments thereto, constitutes the entire
agreement between the parties and supersedes all other prior Agreements and understandings, oral or
written.
b.
Amendment - Company reserves the right to amend this Agreement at any time. Submission of an
application for a policy after Notice of such amendment will constitute agreement of the Broker to such
amendment.
c.
Non-Waiver - Any right(s) not enforced by the Company under this Agreement will not be construed as a
waiver of any of the terms and conditions of this Agreement and the same will remain in full force and
effect. A waiver of any provision in this Agreement will not be deemed to be a waiver of any other
provision, whether or not similar, nor will any waiver of a provision in this Agreement be deemed to
constitute a continuing waiver.
d.
Severability - Any term or provision of this Agreement which is invalid pursuant to the laws and
regulations of that jurisdiction will, as for that jurisdiction, be ineffective. Such term or provision will not
render the remaining terms and provisions of this Agreement invalid. In addition, such term or provision
will not affect the validity of any of the terms or provisions of this Agreement in any other jurisdiction.
e.
Captions - The captions or headings of this Agreement are for convenience and ease of reference only.
They will have no effect on the meaning or interpretation of any provision of this Agreement.
f.
Notice - Notice to the Broker under this Agreement will be provided by the Company and will be deemed
given as follows:
i.
When posted to the "Notices & Schedules" page of the Company’s Website;
ii.
When sent electronically by e-mail to the Broker’s most recent e-mail address on file with the Company;
or
iii. When provided in writing and sent by facsimile, prepaid overnight courier, or first-class mail to the
Broker's most recent address on file with the Company.
All notices to the Company under this Agreement will be provided in writing by the Broker and sent by
first-class mail to:
Prudential Brokerage Appointments
PO Box 70196
Philadelphia, PA 19176
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g.
Governing Law - This Agreement shall be governed by and construed in accordance with the laws of the
State of New Jersey (without regard to the conflicts of laws provisions) thereof and that in all cases where a
party seeks relief in connection with this Agreement in a court of competent jurisdiction, the exclusive
forum and venue shall be the state and federal courts having jurisdiction and venue in the State of New
Jersey.
(The remainder of this page is left blank intentionally.)
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h.
Survival- Upon termination of this Agreement, all authorizations, rights and obligations shall cease except
those contained in sections 7 (Errors and Omissions), 8 (Indemnity), 9 (Complaints, Investigations and
Proceedings), 10 (Compensation), 11 (Privacy), 12 (Anti-Money Laundering), 13(d) (Termination), and 15
(General Provisions).
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed as of the Effective Date:
By my signature below, Broker agrees to be bound by this agreement form number BA_1-2012 and all of its
terms and provisions:
Name of Broker: ______________________________________________________________
Signature:
______________________________________________________________
SS#:
______________________________________________________________
The Prudential Insurance Company of America
Signature:
______________________________________________________________
Vice President, Prudential Select Brokerage
Date:
______________________________________________________________
Pruco Life Insurance Company
Signature:
______________________________________________________________
Vice President, Prudential Select Brokerage
Date:
______________________________________________________________
Pruco Life Insurance Company of New Jersey
Signature:
______________________________________________________________
Vice President, Prudential Select Brokerage
Date:
______________________________________________________________
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Exhibit A -- “List of Eligible Products”
Pursuant to Section 1 of the Broker Agreement, the following is a list of Prudential non-variable individual life
insurance policies for which the Broker is appointed to solicit, procure and submit applications, and assist
policyowners in obtaining service from the Company.
Policies for Pruco Life Insurance Company
PruLife Universal Plus
PruLife Universal Protector
PruLife SUL Protector
Term Elite
Term Essential
PruLife Return of Premium Term
PruLife® Index Advantage Universal Life
Policies for Pruco Life Insurance Company of New Jersey
PruLife Universal Protector
PruLife SUL Protector
Term Elite
Term Essential
PruLife Return of Premium Term
PruLife Universal Plus
PruLife® Index Advantage Universal Life
Exhibit B -- List of Policies and Procedures
Licensing, Appointment and Registration Policy
Replacement Policies and Procedures
BA_1-2012
BROKERAGE FIRM AGREEMENT (LIFE INSURANCE)
This Brokerage Firm Agreement (hereinafter “Agreement”) is made by and between The Prudential
Insurance Company of America, Pruco Life Insurance Company and Pruco Life Insurance Company of
New Jersey, (hereinafter, the preceding three entities referred to collectively as the “Company”), and the
firm whose name appears on page fourteen of this Agreement (hereinafter "Brokerage Firm").
Whereas, Company is an issuer of certain traditional life insurance policies that are not considered
securities under the federal securities laws (hereinafter “Policies”), which are duly qualified under applicable
insurance laws and are identified on the attached Schedule A; and
Whereas, Company and Brokerage Firm wish to enter into an agreement to have Brokerage Firm solicit
applications for Policies.
Now, therefore, for good and valuable consideration, the sufficiency of which is acknowledged hereby, and
intending to be legally bound, the parties agree as follows:
I.
Appointment/Authorization
Company hereby appoints Brokerage Firm during the term of this Agreement as a non-exclusive agent to
solicit applications for Policies. Such Policies are identified as Eligible Products in a List of Eligible Products
that is identified as Schedule A, attached hereto and made a part hereof. Company may update or amend
Schedule A, which will be effective upon notice, as defined in Section XIX, (hereinafter, “Notice”) to the
Brokerage Firm that a new or amended Schedule A has been issued.
II. Authority and Undertakings of the Brokerage Firm
A. Brokerage Firm is authorized hereby to:
1. solicit, procure and submit applications for Policies of the Company through Brokers (defined
below), provided that both the Brokerage Firm and the applicable Broker are properly licensed
and state appointed to do so, in accordance with applicable law and regulations and the
Company’s Licensing, Appointment and Registration policy, as amended from time to time. For
purposes of this agreement, “Broker” is defined as an individual employed by, associated with
(whether as a registered representative of the Brokerage Firm if the Brokerage Firm is a Broker
Dealer or otherwise), or otherwise acting on behalf of Brokerage Firm and who is appointed as
a non-exclusive agent of the Company.
B. Brokerage Firm agrees to the following undertakings in its capacity as a Brokerage Firm with
regard to any of its Brokers for Policies:
1. Brokerage Firm has full responsibility for the training and supervision of all Brokers who are
engaged, directly or indirectly, in the offer, sale and/or administration of Policies to ensure that
they are in compliance with all applicable federal, state and local laws and regulations and all
rules and procedures of the Company (which rules and procedures may be changed by the
Company at its own discretion.) Brokerage Firm shall establish and implement procedures for
the supervision of the sales practices of all of its Brokers.
2. Brokerage Firm shall be responsible for determining the suitability for recommendations and
sales for Brokers of Policies.
3. Brokerage Firm shall be responsible for the delivery of all Policies, amendments thereto and all
other documents to each Policy owner, and shall ensure that all other delivery requirements
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have been satisfied, promptly and in accordance with the Company’s delivery requirements;
require return of unplaced Policies; review all applications before submitting them to the
Company and will submit only those applications that have been properly completed and for
which Brokerage Firm and Brokers have the licenses and appointments required by the
Company.
4. Brokerage Firm is authorized to designate Brokers for appointment by Company to solicit
applications for Policies. Brokerage Firm shall not propose a Broker for appointment unless he
or she duly is licensed as an insurance agent in the state(s) in which it is proposed he or she
shall solicit applications for Policies. Brokerage Firm shall assist the Company in the
appointment of Brokers in conformance with applicable insurance laws and such rules and
procedures as may be established by Company. Brokerage Firm shall conduct a thorough and
diligent investigation of the trustworthiness, competence, character, reputation and criminal
background of each Broker that satisfies the requirements for appointment of an agent in each
state the individual is to be appointed, the Violent Crime Control and Law Enforcement Act of
1994 (18 U.S.C. Sect. 1033 and 1034) (hereinafter the “Crime Bill”) prior to proposing them for
appointment and any other applicable laws. Brokerage Firm shall recommend for appointment
only those Brokers known to be of good character, trustworthy, financially responsible and
competent to serve as an agent for Company, and who otherwise qualify for appointments
under the applicable state insurance laws when proposed for appointment. Additionally, the
Brokerage Firm shall notify the Company immediately if the Brokerage Firm has knowledge
that any person who was recommended for appointment and who was appointed by the
Company no longer meets the qualification requirements of applicable state insurance laws.
The Company shall have sole discretion to appoint, refuse to appoint, discontinue, or terminate
the appointment of any Broker. Upon the Company giving Notice to Brokerage Firm of its
withdrawal of authority of a Broker to solicit applications, Brokerage Firm will immediately
ensure that any such Brokers cease all such activities.
5. Brokerage Firm shall assist Policy owners in obtaining prompt service from the Company with
respect to the administration of Policies and in maintaining their coverage.
III. Limitations of Brokerage Firm’s Authority
Brokerage Firm’s authority is limited to what is authorized in Section II. This Section is intended to provide
examples, not an entire listing, of actions that are outside the authority granted in Section II. Brokerage
Firm agrees that its authority is limited to the solicitation and marketing of Policies in accordance with this
Agreement. Brokerage Firm represents and agrees on behalf of itself and all of its Brokers that none of
them will act in a manner not authorized by this Agreement and that any such unauthorized actions,
including but not limited to, the following actions, would be considered a breach of this Agreement. The
Brokerage Firm is not authorized to:
A. make, alter, modify or discharge any Policy or other form; waive any provision or condition of a
Policy; bind the Company; extend the time of paying any premium; accept or receive promissory
notes for payment of premium.
B. adjust or settle any claim, or commit the Company with respect to any claim, incur any expense or
liability on account of the Company except as specifically directed or authorized in writing by the
Company.
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C. expend, nor contract for the expenditure of the funds of Company, nor incur any liability on behalf
of Company, without specific written authority to do so from the Company.
D. make representations as an agent of the Company in any manner or for any purpose except as
specifically authorized by this Agreement.
E. provide or offer to provide any inducement not specified in the Policy or any rebate, either directly
or indirectly, to any person or entity, as an inducement to purchase any Policy.
F. obtain signed forms from applicants or Policy owners unless the forms are completed for
submission to the Company. Brokers may not request that an applicant or Policy owner pre-sign
any Policy form for use at a later date nor may the Brokerage Firm pre-sign any form for use at a
later date.
G. deliver or allow the delivery of a Policy unless the health of the proposed insured(s) is in
accordance with the Company’s requirements, if any, and, where required, the first premium is paid
in full.
H. make any misrepresentation or incomplete comparison for the purpose of inducing a potential or
actual Policy owner to purchase, convert, lapse, surrender all or any portion of, forfeit, borrow from,
or replace any Policy;
I. induce or attempt to induce any Policy owner to replace or relinquish a Policy or to withdraw values
from a Policy when doing so would be in violation of the Company’s Replacement Policy or any
state or federal law or regulation or not in the interest of the customer.
J. accept any payments for Policies, unless the funds are made payable to the Company as provided
in Section VII.
K. engage in any insurance transaction that requires compensation disclosure, as determined by the
applicable law, without making such required compensation disclosure.
L. solicit applications for Policies on military installations or otherwise engage in activity contrary to
instruction provided by the US Department of Defense or state law regarding such.
M. solicit, procure or submit applications for the SEC registered life insurance policies, annuity
contracts and private placement variable contracts of the Company which are controlled by selling
agreements between FINRA member broker dealers.
N. demand or accept any remuneration other than what is provided by the Company for rendering any
service specifically related to the normal maintenance and care of the Company’s business. This
provision does not prohibit the Brokerage Firm from accepting fees for any services provided by
Brokerage Firm other than those authorized by this Agreement.
IV. Brokerage Firm Representations
Brokerage Firm represents and agrees on behalf of itself and all of its Brokers:
A. that solicitation and all activities by Brokerage Firm shall be undertaken only in accordance with
applicable laws and regulations. No Broker of Brokerage Firm shall solicit applications for Policies
until the Broker and Brokerage Firm are duly licensed and appointed by Company in accordance
with applicable laws and regulations and in accordance with the Company’s Licensing,
Appointment, and Registration Policy, in the appropriate states or other jurisdictions.
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B. that neither it nor its Brokers are authorized by Company to give any information or make any
representation in connection with this Agreement or the offering of the Policies other than those
contained in marketing material authorized in writing by Company.
C. to abide by the Company’s policies and procedures related to the solicitation and sale of Policies,
which are identified on Schedule B, attached hereto and made a part thereof.
D. that the Brokerage Firm and its employees or representatives will comply with all applicable
insurance laws, regulations and requirements and all other applicable state and federal laws,
regulations and requirements in soliciting applications for Policies; that the Brokerage Firm will be
fully responsible for all acts of its employees or representatives in soliciting applications for
Policies.
E. that, except as disclosed to the Company on Brokerage Firm’s or Brokers’ application for
appointment or otherwise in writing, neither Brokerage Firm’s insurance license nor the insurance
license of any of its Brokers has ever been revoked, suspended, or rescinded in any state or
jurisdiction; neither Brokerage Firm nor any of its Brokers has ever been fined by any insurance
regulator in an amount of $5,000 or more; and neither Brokerage Firm nor any of its Brokers are
currently the subject of any disciplinary proceeding or investigation in any state or jurisdiction by
any Department of Insurance, Attorney General’s office or other government authority.
F. that, except as disclosed to the Company on Brokerage Firm’s or Brokers’ applications for
appointment or otherwise in writing, if Brokerage Firm or any of its Brokers are or have ever been a
registered principal or representative of a member of FINRA, the said registration with FINRA is not
now and never has been suspended, revoked or canceled; that neither Brokerage Firm nor any of
its Brokers have ever been fined by FINRA or any other self-regulatory organization in the amount
of $5,000 or more; that neither Brokerage Firm nor any of its Brokers are currently the subject of
any disciplinary proceeding or investigation by the SEC or FINRA; that neither Brokerage Firm nor
any of its Brokers have ever been convicted of any criminal felony involving dishonesty or breach
of trust or of any other offense set forth in the Crime Bill; that Brokerage Firm performs the due
diligence required by law to ensure that Brokerage Firm, its employees or other representatives,
including but not limited to any of its Brokers, engaging in the business of insurance, are, and for
the term of this Agreement shall continue to be, in compliance with the requirements of the Crime
Bill.
G. that Brokerage Firm, upon request of Company, shall, within thirty (30) days of receipt, return to
Company a questionnaire or certification regarding any regulatory, civil and/or criminal
proceedings, including arbitration, against the Brokerage Firm or Broker commenced or concluded
by any state insurance or securities department, FINRA, the SEC or other self-regulatory
organization and/or in any court of competent jurisdiction. Brokerage Firm shall provide Company
with a full explanation regarding matters disclosed in the questionnaire or certification. Additionally,
Brokerage Firm shall notify Company of any regulatory investigation, fine or sanction concerning
an individual or firm who is authorized to represent Company under this Agreement.
H. that neither Brokerage Firm nor any of its Brokers will solicit applications for Policies in any state,
jurisdiction or commonwealth unless the Policy has been approved for sale by the appropriate
regulatory authority in that state, jurisdiction or commonwealth.
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I. that Brokerage Firm will promptly notify the Company of any allegation that the Brokerage Firm, or
any of its employees or representatives, violated any law or regulation which may impact their
ability to represent the Company.
J. that Brokerage Firm shall furnish the Company with proof of proper insurance licensing for itself
and its Brokers. Brokerage Firm will also notify the Company in writing immediately of the
termination of the employment or affiliation of a Broker who is appointed to represent the Company
pursuant to this Agreement.
K. that Brokerage Firm agrees to submit to the Company cases from Brokerage Firm which have
been packaged for underwriting purposes. Such case packages should include the application, a
copy of the as-sold illustration, all relevant financial information, and either copies of relevant
attending physicians’ statements and other required medical information or a listing of the medical
underwriting requirements Brokerage Firm has ordered. Brokerage Firm further agrees to submit
informal or inquiry case packages for underwriting purposes that include only the relevant
information needed to assess the risk; that in obtaining and assembling this information it is acting
as the representative of the applicant, proposed insured and not as an agent of the Company.
L. that Brokerage Firm agrees that all terms and conditions of this Agreement apply to Brokerage
Firm and any Broker, and any employee of Brokerage Firm or other representative, including but
not limited to all of its Brokers, employees or other representatives, who performs any other
function on behalf of Brokerage Firm; Brokerage Firm further agrees to ensure that such Brokers,
employees or other representatives comply with all terms and conditions of this Agreement.
Furthermore, Brokerage Firm agrees to notify Company immediately if Brokerage Firm or any of its
Brokers, employees or other representatives breach any terms and conditions of this Agreement.
M. that no Company Policy shall be sold where, at the time of delivery, the Brokerage Firm or anyone
associated with Brokerage Firm has knowledge that there is a practice or plan to initiate a life
insurance policy for the benefit of a third party investor who, at the time of such policy origination,
has no insurable interest in the insured.
N. that Brokerage Firm and anyone associated with Brokerage Firm will not participate directly or
indirectly in any transaction where a Company Policy is sold to or used in any manner with a
viatical or life settlement company or is part of a viatical or life settlement.
O. that submission of an application for a Policy is proof that the Brokerage Firm has approved the
transaction.
P. that Brokerage Firm shall pay all expenses incurred by it in the performance of this Agreement
unless specifically provided for in this Agreement or in a writing signed by the Company and
Brokerage Firm.
Q. that with regard to any bank marketing, Brokerage Firm will comply with the disclosure and
advertising requirements implemented by the Board of Governors of the Federal Reserve System,
the Federal Deposit Insurance Corporation, the Office of the Comptroller of the Currency, the
Office of Thrift Supervision and all other applicable laws and requirements, including but not limited
to disclosures with respect to the sale or recommendation of Policies, marketing material and
illustrations.
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R. to complete a permanent registration for the PrudentialXpress website at www.pruxpress.com
(hereinafter the “Website”) within 30 days of the effective date of this Agreement. Use of the
Website will be subject to the terms and conditions of the Website.
S. for the term of the Agreement, to access the Website no less frequently than once every 90 days
and to read and review the “Notices & Schedules” page of the Licensing Section.
T. for the term of the Agreement, to maintain an active Website registration.
V. Independent Contractor
Brokerage Firm is an independent contractor under this Agreement. Nothing herein contained shall make
Brokerage Firm, or any of its Brokers, employees or other representatives, an employee of Company.
Neither Brokerage Firm nor any of its Brokers, employees or other representatives shall hold themselves
out to be employees of Company in any dealings with the public. Brokerage Firm and any of its Brokers
are free to exercise independent judgment as to the time, place and means of performing the authority
granted, subject to the terms and conditions of this Agreement. Brokerage Firm’s business and any
services provided by Brokerage Firm and any of its Brokers, other than those authorized by this
Agreement, are not and will not be represented to be the business of the Company.
VI. Advertisements and Marketing Materials
The Brokerage Firm agrees that any material it develops, approves or uses for sales, training, explanatory or
other purposes that mentions by name the Policies or Company (or any affiliate of the Company or any logos of
any of them) will not be used without prior written consent of the Company. Brokerage Firm will not publish,
issue, circulate or use in any manner whatsoever any advertisements or marketing materials describing or
referring to the Company, the Policies or any product of the Company unless such advertisements or
marketing materials have been approved in writing in advance by the Company.
Brokerage Firm will not misrepresent the Policies or the Company and will make no oral or written
representation which is inconsistent with the terms of the Policies or with the information in any illustration
or sales literature furnished by the Company.
VII.
Payments
A. Neither Brokerage Firm nor any of its Brokers can accept cash or any other form of payment made
payable to the Brokerage Firm or Broker.
B. Brokerage Firm and its Brokers may accept a check or money order made payable to the
Company, but only under the following circumstances:
1. when the application and the check are submitted simultaneously and the Company’s
standards for prepaid applications have been met, or
2. the Company’s delivery requirements have been met and the Policy has been delivered.
C. The check or money order must be forwarded to the Company within one business day of receipt
by the Brokerage Firm or its Broker.
VIII. Compensation
A. Company shall arrange for the payment of compensation to Brokerage Firm as compensation for
the sale of Policies by a Broker of Brokerage Firm. The amount of compensation payable under
this section (hereinafter “Compensation”) shall be in accordance with the Company’s Commission
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Schedule in effect as of the date of Policy issue, as determined by the Company, for each Policy.
If the Company determines the Brokerage Firm is eligible for any expense allowances or a
Compensation arrangement that differs from the commission schedules posted to the Website,
such Compensation will be communicated to the Brokerage Firm in writing in a separate Schedule.
No Compensation is payable unless the Brokerage Firm and Broker have first complied with all
applicable insurance laws, rules and regulations and such payments would not constitute a
violation of such insurance laws, rules and regulations, anything in this Agreement to the contrary
notwithstanding. The Brokerage Firm will only be entitled to compensation for Policies that have
been submitted by the Brokerage Firm, accepted by the Company, delivered to the Policy owner and
where all the requirements of the Company’s Licensing, Appointment and Registration Policy have
been satisfied (hereinafter “Policies Placed by Brokerage Firm”).
B. If the Company returns, for any reason, any premiums or purchase payments on any Policy,
rescinds the Policy or considers the Policy to be void from inception, the Brokerage Firm will have
an immediate obligation to, and will upon demand, repay the Company all the Compensation
previously paid to the Brokerage Firm as a result of those premiums or purchase payments.
C. The Company shall have and be entitled to exercise a right of offset for any amounts due the
Company from Brokerage Firm against any and all Compensation otherwise payable to Brokerage
Firm under this Agreement.
D. When the Brokerage Firm is involved in a sale with any other insurance producer appointed with
the Company, Compensation will be payable in proportion as directed on the application or in a
writing acceptable to the Company.
E. No compensation will be paid on any premium that is waived.
F. If a Policy replaces, in whole or in part, a life insurance policy or annuity contract previously issued
by this Company, the Company has the right to determine what, if any, compensation will be
allowed.
G. No Compensation will be paid on any Policy issued as a result of the conversion of group life
insurance.
H. Compensation set forth in the Schedule C of this Agreement is subject to change at any time upon
Notice to Brokerage Firm. Changes will not affect Compensation for any Policy placed prior to the
effective date of the change.
I.
Service Compensation, if applicable as defined in Schedule C, shall be payable for the period and
upon the terms set forth in Schedule C.
J. No assignment of Compensation is valid against the Company unless directed by Brokerage Firm
and agreed upon by Company and unless allowable under all applicable laws.
K. Notwithstanding any provision of this Agreement to the contrary, if the transaction is subject to the
jurisdiction of the New York Insurance Department, no Compensation in excess of the
compensation limits established by the Insurance Law of the State of New York will be due or
payable by the Company to Brokerage Firm.
L. No Compensation is payable on any extra war risk premium which may be charged in connection
with any Policy.
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M. If a Policy is changed to a different kind or amount, or if its date is changed, the Company will
recalculate Compensation as of the date of the change. Additional Compensation will be paid or
recaptured as a result of this calculation.
N. Compensation on premiums paid more than three months in advance are payable on the date the
premiums are due.
O. No compensation shall be paid, and any compensation previously paid shall be returned to the
Company on request, if the Company, in its sole discretion, determines not to issue the Policy(s)
applied for, refunds the premium paid pursuant to any request by the Policy owner, refunds any
premium paid as the result of a complaint by the Policy owner, remits paid premiums to a federal or
state court if the Company elects to do so with regard to litigation involving the Policy or determines
that any person or entity required to be licensed for the solicitation of Policies is not duly licensed to
sell such Policies in the appropriate jurisdictions.
P. Upon the termination of this Agreement, the Company will pay Compensation to the Brokerage
Firm on any renewal Compensation which would otherwise be due on business placed with
Company prior to the termination date of this Agreement unless such receipt of renewal
Compensation is determined to violate current directives to the contrary as provided by state or
federal law or regulation or a court of competent jurisdiction.
Q. Compensation due is vested to the Brokerage Firm for the period set forth in the attached
Schedule C and if such receipt of Compensation is permitted by applicable state and federal law.
R. The Company will determine the amount of Compensation payable for a Policy placed by
Brokerage Firm, where the compensation was not included in Schedule C at the time of sale.
IX. Books And Records
Brokerage Firm shall have the responsibility for maintaining its records and the records of all of its Brokers.
Brokerage Firm shall maintain such other records as are required of it by applicable federal and state laws
and regulations. These records will be made available to the Company for inspection upon request,
including after termination of this Agreement. The books and records maintained by Brokerage Firm under
the terms of this Agreement that relate to the sale of the Policies, shall be maintained so as to clearly and
accurately disclose the nature and details of the transactions as required by appropriate laws, rules and
regulations and for the period required by law. Brokerage Firm and all of its Brokers shall also comply with
any record hold order issued by the Company.
X. Complaints, Investigations and Proceedings
A. Brokerage Firm agrees to immediately provide Notice to Company of any Policy complaints,
investigations or disciplinary proceedings received by Brokerage Firm or any of its employees or
representatives relating to the Policies, Company or any threatened or filed action or civil litigation
arising out of the conduct of business under this Agreement. Additionally, Brokerage Firm shall
immediately forward to Company, by certified mail and to the address provided for Notice in this
Agreement any legal process or notice of claims served on Brokerage Firm or any of its employees
or representatives in a suit or proceeding against Brokerage Firm or any of its employees or
representatives arising out of the conduct of business under this Agreement.
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B. Brokerage Firm and any of its employees and representatives shall cooperate with Company in
investigating and responding to any complaint, attorney demand, or inquiry received from state
insurance departments or other regulatory agencies or legislative bodies, and in any settlement or
trial of any actions arising out of the conduct of business under this Agreement. Cooperate, as
referred to in this provision, shall include, but is not limited to, the provision of information as may
be necessary to furnish Company with a complete understanding of the facts and circumstances
surrounding the complaint, demand or inquiry.
C. Any response by Brokerage Firm or any of its employees or representatives to a Policy complaint
arising out of the conduct of business under this Agreement must be sent to Company for its
approval before being sent. Any responses to such Policy complaints must be sent to Company
not less than fifteen (15) business days before being sent, except that if a more prompt response is
required, the proposed response may be communicated to Company.
D. Brokerage Firm and any of its employees or representatives are not authorized, and are expressly
forbidden, from settling or offering to settle any complaint or litigation from a Policy owner,
assignee, beneficiary or other party in interest to a Policy.
XI. Term of Agreement; Suspension; Termination; Survival
A. This Agreement shall be in force from its Effective Date and thereafter shall remain in force, except
that either party may unilaterally terminate this Agreement immediately upon Notice to the other
party of its intention to do so.
B. This Agreement may be terminated for cause by the Company for, but not limited to, any of the
following reasons:
1. fraud by Brokerage Firm or Brokers;
2. material misrepresentations by Brokerage Firm or Brokers regarding the Company or the
Company’s products, or the performance of either;
3. conversion of funds by Brokerage Firm;
4. breach of this Agreement;
5. the suspension, revocation, cancellation or rescission of any state insurance license; or
6. insolvency of Brokerage Firm.
C. Termination for any of the reasons set forth in sub-sections B.1. through B.4. will occur immediately
upon Notice to Brokerage Firm. Termination for the reasons set forth in sub-sections B.5. and B.6.
will occur automatically at the date and hour of the action described in sub-sections B.5. and B.6.
D. Either party shall have the right to suspend Brokerage Firm’s right to solicit and sell Policies to
potential Policy owners, by giving the other Notice of the suspension.
E. Upon termination of this Agreement, all authorizations, rights and obligations shall cease except
those contained in Sections VIII (Compensation), IX (Books and Records), X (Complaints and
Investigations), XII (Indemnity), XIII (Errors and Omissions), XIV (Privacy) and XV (Anti-Money
Laundering).
XII. Indemnity
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A. Indemnification by Company – Company agrees to indemnify and hold harmless Brokerage Firm,
its directors, trustees, and officers, (collectively, the “Indemnified Parties” for the purposes of this
Section) against any and all losses, claims, damages, liabilities (including amounts paid in
settlement) or litigation expenses (including legal and other expenses), to which the Indemnified
Parties may become subject as a result of any untrue statement of any material fact contained in
any sales materials furnished by the Company or approved in writing by the Company relating to
the Policies, or as a result of the omission to state therein a material fact required to be stated
therein or necessary to make the statements therein not misleading.
B. Indemnification by the Brokerage Firm - Brokerage Firm shall indemnify, defend and hold harmless
the Company and any director, officer, corporate agent, employee, attorney and any representative
thereof, from and against all losses, expenses, claims, damages and liabilities (including any costs
of investigation and legal expenses and any amounts paid in settlement of any action, suit or
proceeding of any claim asserted) which result from, arise out of or are based upon:
1. any breach by Brokerage Firm, its Brokers, employees or other representatives of any
provision or term or condition of this Agreement;
2. any violation by Brokerage Firm or any of its Brokers, employees or other representatives of
any federal, state, local or foreign law or regulation;
3. any claim by a Broker against the Company for Compensation; or
4. bad faith, negligence, misconduct, willful malfeasance or omissions of the Brokerage Firm or
any of its Brokers, employees or other representatives in the solicitation of applications for, or
sales of, Policies or any other unlawful sales practices or conduct.
C. If a party is named in any lawsuit or other proceeding for which such party believes it may be
entitled to indemnification hereunder, such party will:
1. Promptly notify the indemnifying party of any such proceeding, investigation, or litigation and
furnish the indemnifying party with a copy of any notices, pleadings and other correspondence;
2. Provide the indemnifying party reasonable opportunity to consult with the indemnified party in
the development of strategy and the substantive position to be taken, and the determination of
the course of action to be taken; and
3. Consider in good faith any suggestion made by the indemnifying party and follow the
recommendations of the indemnifying party, including its recommendations as to settlement,
compromise or other agreed upon resolution of the proceeding, provided there is a reasonable
basis for such recommendations and there is no material adverse effect on the indemnified
party.
D. The Indemnifying Party, upon the request of the indemnified party, shall retain counsel reasonably
satisfactory to the indemnified party to represent the indemnified party and any others the
indemnifying party may designate in such proceeding and shall pay the fees and disbursements of
such counsel related to such proceeding.
XIII. Errors and Omissions
The Brokerage Firm agrees to maintain errors and omissions coverage with unimpaired limits of not less
than one million dollars and to provide evidence of such coverage satisfactory to the Company upon
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request by the Company. The Brokerage Firm will notify Company in writing immediately if the coverage is
terminated or suspended.
XIV.
Privacy
Each party acknowledges that they may be provided with information or access information about
customers of Company or Brokerage Firm (“Customer Information”). Each party agrees to comply with all
federal, state, provincial and/or local law or regulation related to privacy. Furthermore, each party
represents and warrants that it has implemented and currently maintains an effective information security
program to protect the Customer Information, which program includes administrative, technical, and
physical safeguards:
A. to ensure the security and confidentiality of Customer Information;
B. to protect against any anticipated threats or hazards to the security or integrity of such Customer
Information; and
C. to protect against unauthorized access to or use of Customer Information which could result in
substantial harm or inconvenience to either party, or to customers of any of them.
Brokerage Firm shall promptly notify Company if Brokerage Firm is in material breach of this provision.
Brokerage Firm shall promptly notify Company if it has suffered a breach of security of personal
information affecting any consumer to whom Brokerage Firm has sold any Company Policy.
Each party agrees that it shall keep and maintain all Confidential Information (as defined below) in strict
confidence, using such degree of care as is appropriate to avoid unauthorized use or disclosure; and shall
use and disclose Confidential Information solely for the purposes for which such information, or access to
it, is provided pursuant to the terms of this Agreement. Each party further agrees that it shall not, directly
or indirectly, disclose Confidential Information to any third party, except with the disclosing party’s prior
written consent or as permitted under the terms of this Agreement.
For purposes of this provision, Confidential Information is defined as information respecting all past,
present or future business activities of each party, written or oral, including without limitation: information
relating to a party’s planned or existing businesses or initiatives; organizational restructuring plans; actual
and projected sales, profits and other financial information; technology (computer systems and
architecture, computer hardware and software, methods); processing and operational methods; insurance,
annuities and financial services product strategies, actuarial calculations, designs, administration and
management; tax interpretations or positions; information respecting or materials of third parties with
whom a party conducts business; and employees and personnel; and any policies, procedures and
standards. Notwithstanding the foregoing, Confidential Information does not include information that (i) is
lawfully made available to the general public, (ii) is or becomes generally known to the public not as a
result of a disclosure by the receiving party, (iii) is rightfully in the possession of the receiving party prior to
disclosure by the disclosing party, (iv) is received by a party in good faith and without restriction from a
third party reasonably believed to have the right to make such disclosure, or (v) is independently
developed by or for the receiving party without use or reference to the Confidential Information.
XV. Anti-Money Laundering
A. Brokerage Firm represents and agrees that its employees and representatives have reviewed and
are familiar with (i) applicable laws, regulations, rules and guidance governing the detection,
prevention and reporting of money laundering and terrorist financing activities, including, but not
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limited to: (1) provisions of the USA PATRIOT Act of 2001 and regulations thereunder; (2)
provisions of the Bank Secrecy Act and regulations thereunder; (3) relevant rules and regulations
promulgated by the Office of Foreign Assets Control; and (4) all record keeping, reporting and
auditing requirements of these laws, regulations and rules; and (ii) Company’s Anti-Money
Laundering Program.
B. Brokerage Firm agrees that its employees and representatives who are appointed with Company
will complete Company’s Anti-Money Laundering training provided by LIMRA, or such training
approved in advance by Company in writing, concerning the detection, prevention and reporting of
money laundering and terrorist financing activities, when and as required by Company. Brokerage
Firm agrees to provide Company with a certification, upon request, that it has completed such
training and detailing the subject matter and dates of such training and the persons trained.
C. Brokerage Firm agrees to report to Company any transaction, or pattern of transactions, that it
knows, suspects, or has reason to suspect: (i) involves funds derived from illegal activity (including,
without limitation, the ownership, nature, source, location, or control of such funds or assets) as
part of a plan to violate or evade any federal law or regulation or to avoid any transaction reporting
requirement under federal law or regulation or is intended or conducted to hide or disguise funds or
assets derived from illegal activity; (ii) is designed, whether through structuring or other means, to
evade the requirements of the Bank Secrecy Act or any regulations promulgated thereunder; (iii)
has no business or apparent lawful purpose or is not the sort in which the particular customer
would normally be expected to engage; or (iv) involves the use of Company to facilitate criminal
activity. Brokerage Firm agrees to comply with any requests from Company for assistance in the
detection or investigation of potential suspicious transactions in a timely manner. Brokerage Firm
agrees and acknowledges that notice to any individual of any investigation or reporting involving a
suspicious transaction or activity is prohibited by federal law and agrees to ensure the
confidentiality of any such investigation or reporting.
D. Brokerage Firm agrees to permit inspection relating to its compliance with the foregoing by any
U.S. federal regulatory or law enforcement agency having jurisdiction and will make available to
examiners from such agencies such records and information as they may request relating thereto.
E. Company shall have the right, upon reasonable notice, to obtain and review documentation
evidencing compliance with Company’s Anti-Money Laundering Program and the foregoing laws,
regulations and rules.
XVI.
General Provisions
A. Assignability – This Agreement shall not be assigned by either party without the prior written
consent of the other.
B. Non-Waiver - Any right(s) not enforced by the Company under this Agreement will not be
construed as a waiver of any of the terms and conditions of this Agreement and the same will
remain in full force and effect. A waiver of any provision in this Agreement will not be deemed to
be a waiver of any other provision, whether or not similar, nor will any waiver of a provision in this
Agreement be deemed to constitute a continuing waiver.
C. Severability - Any term or provision of this Agreement which is invalid pursuant to the laws and
regulations of that jurisdiction will, as for that jurisdiction, be ineffective. Such term or provision will
not render the remaining terms and provisions of this Agreement invalid. In addition, such term or
BFA-C_1-2012
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provision will not affect the validity of any of the terms or provisions of this Agreement in any other
jurisdiction.
D. Captions - The captions or headings of this Agreement are for convenience and ease of reference
only. They will have no effect on the meaning or interpretation of any provision of this Agreement.
E. Amendment - The Company reserves the right to amend this Agreement at any time. Submission
of an application for a Policy after Notice of such amendment will constitute agreement of the
Brokerage Firm to such amendment.
F. Entire Agreement – Except for a long-term care broker, Brokerage General Agency and/or BrokerDealer Agreement, this Agreement and its Schedules and Addendums constitute the entire
agreement between the parties and supersedes all prior agreements and understandings, oral and
written.
XVII. Effective Date
This Agreement is effective once fully executed by both the Company and the Brokerage Firm. The
Effective Date shall be the date the Company executes the Agreement.
XVIII. Governing Law
This Agreement shall be governed by and construed in accordance with the laws of the State of New
Jersey (without regard to the conflicts of laws provisions) thereof and that in all cases where a party seeks
relief in connection with this Agreement in a court of competent jurisdiction, the exclusive forum and venue
shall be the state and federal courts having jurisdiction and venue in the State of New Jersey.
XIX.
Notice
Notice to the Brokerage Firm under this Agreement will be provided by the Company and will be deemed
given as follows:
A. When posted to the “Notices & Schedules” page of the Company’s Website;
B. When sent electronically by e-mail to the Brokerage Firm’s most recent e-mail address on file with
the Company; or
C. When provided in writing and sent by facsimile, prepaid overnight courier, or first-class mail to the
Brokerage Firm’s most recent address on file with the Company.
(The remainder of this page is left blank intentionally.)
BFA-C_1-2012
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All notices to the Company under this Agreement will be provided in writing by the Brokerage Firm and sent
by facsimile, prepaid overnight courier, or first-class mail to:
The Prudential Insurance
Company of America
Prudential Brokerage
Appointments
PO Box 70196
Philadelphia, PA 19176
The Pruco Life Insurance Company
Prudential Brokerage
Appointments
PO Box 70196
Philadelphia, PA 19176
The Pruco Life Insurance
Company of New Jersey
Prudential Brokerage
Appointments
PO Box 70196
Philadelphia, PA 19176
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be duly executed as of the
dates set forth below.
By signature below, Brokerage Firm agrees to be bound by this agreement form number BFA-C_1-2012
and all of its terms and provisions.
Name of Brokerage Firm:
_________________________________
Principal:
_________________________________
Signature:
_________________________________
Tax ID #:
________________________________
Brokerage Firm’s e-mail address: ________________________________
Prudential Insurance Company of America
Pruco Life Insurance Company of New
Jersey
By: ___________________________
By: ___________________________
Vice President, Prudential Select Brokerage
Date:__________________
Vice President, Prudential Select Brokerage
Date:__________________
Pruco Life Insurance Company
By: ___________________________
Vice President, Prudential Select Brokerage
Date:__________________
BFA-C_1-2012
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SCHEDULE A
Policies for Pruco Life Insurance Company
PruLife® Universal Plus (“UL”)
PruLife® Universal Protector (“UL”)
Term EliteSM
Term EssentialSM
PruLife® Return of Premium Term
PruLife SUL Protector
PruLife® Index Advantage Universal Life
Policies for Pruco Life Insurance Company of New Jersey
PruLife Universal Protector (“UL”)
Term EliteSM
Term EssentialSM
PruLife® Return of Premium Term
PruLife SUL Protector
PruLife Universal Plus (“UL”)
PruLife® Index Advantage Universal Life
SCHEDULE B
List of Policies and Procedures
Licensing, Appointment and Registration Policy
Replacement Policies and Procedures
Anti-Money Laundering Program
BFA-C_1-2012
The Prudential Insurance Company of America
PO BOX 1143
Minneapolis, MN 55440-1143
(800) 286-7745
www.prudential.com
I authorize Prudential to deposit compensation payments directly to the Account named below when
appropriate. This authorization shall remain in full force and effect until Prudential has received, and has
reasonable opportunity to act upon, the written notification from me of its termination. (Please allow 1-2 pay
cycles for processing).
I authorize the Company to adjust this account for any funds erroneously credited by the Company.
Name:
Social Security or Tax Identification Number:
Contract Number:
Bank Name:
Bank Street Address:
City, State and Zip Code:
Bank Branch Number:
Check One:
•
Checking - Attach a voided or canceled check indicating bank’s
name and address (photocopies acceptable).
Checking
Account Number:
•
Savings -
Savings
Account Number:
Attach a deposit slip indicating the bank’s name and
address (photocopies acceptable).
Bank Transit
Routing Number:
(9 -digits)
Signature:
Date:
Please return completed form using one of the following:
Fax:
(800) 416 - 5022
U.S. Mail:
The Prudential Insurance Company of America
Prudential Brokerage Compensation
Post Office Box 1143
Minneapolis MN 55440 - 1143
Intra - company Mail:
Prudential Brokerage Services Division
Producer Compensation & Administration
1st Floor
NCPO
A Prudential business
EF